Suture lateralization in congenital bilateral vocal cord immobility in neonates and infants: A hybrid approach.

INTRODUCTION: Bilateral vocal cord immobility (BVCI) is a leading cause of stridor and airway obstruction in neonates which may arise idiopathically, as a result of birth trauma, or in the setting of Central nervous system lesions such as Arnold-Chiari malformation. Although many children with BVCI may be managed conservatively, surgical intervention may be necessary in those patients with ongoing upper airway obstruction. Many interventions have been described including, tracheostomy, cordotomy, cricoid splitting procedures, and arytenoidectomy. Vocal cord suture lateralization has the advantage of being both reversible and less morbid than other surgical interventions for BVCI. This study describes a novel variation of the suture lateralization procedure which aids in correct placement of the suture thus minimizing multiple needle passes and associated laryngeal edema. METHODS: A retrospective chart review was undertaken of five patients undergoing suture lateralization of the vocal cord for BVCI at a single institution over a 10 year period. Post-operative voice and swallow outcomes were recorded. RESULTS: Of five patients undergoing this procedure four returned to normal diet. One was diagnosed with a progressive neurological disorder and was persistently fed via gastrostomy tube. Three of the five patients spontaneously recovered vocal cord function and went on to have normal voice after suture removal. CONCLUSION: Suture lateralization is a safe and effective means of alleviating upper airway obstruction in BVCI. It has the advantages of being reversable and minimally invasive; however, optimal suture placement is both vital and challenging. The novel technique described in this study allows identification of landmarks as and aid to suture placement thus reducing the need for multiple needle passes into the lumen of the larynx.

Stromal vascular fraction improves the durability of autologous fat temple augmentation-A split-face randomized study using ultrasound biomicroscopy.

BACKGROUND: Autologous lipotransfer aims to restore aging-associated volume loss, but with low predictability owing to 20-90% first-year loss of transferred fat. Enrichment by adipose-derived stem cells within the stromal vascular fraction (SVF) aims to improve volume retention through their differentiation potential and paracrine actions exerted by secreted trophic and angiogenic factors. Assessing studies lacked split-face designs, and used multitudes of enrichment ratios, preparation techniques and evaluation methods ending in contradictory reports regarding enrichment advantage. AIM: To test whether enriching the autologous fat graft with SVF will increase its residual volume as compared to non-enriched graft. A standardized enrichment protocol and ratio and objective assessment were employed. PATIENTS AND METHODS: In a split-face design, and after random assignment, bilateral temple augmentation using non-enriched versus SVF-enriched autologous lipotransfer were compared in middle-aged females otherwise healthy non-pregnant or breast-feeding females abstaining from esthetic or weight-controlling procedures. Temple volume scale (TVS), skin layers' thickness measured by ultrasound biomicroscopy (UBM), visual analog scale for patients' satisfaction, and side effects were blindly assessed at 1 week, 3 months, and 6 months. RESULTS: In the included 15 females, TVS was significantly lower (0.5 ± 0.5 versus 1.1 ± 0.7, P = 0.0001), and% hypodermal augmentation was significantly higher (70.92 ± 58.09 versus 18.93 ± 19.33, P = 0.001) on the SVF-enriched side at 6 months. Patient satisfaction was similar bilaterally (P = 1), as were sequelae frequencies as lumping, edema, and ecchymosis. CONCLUSION: SVF enrichment of transferred fat significantly improved its residual volume at 6 months; a conclusion that needs further validation. UBM was an informative objective tool for the following temple skin thickness changes. Trial registration clinical trials.gov (NCT03965936).

Pediatric tracheostomy first tube change: When is it safe?

OBJECTIVES: The first tracheostomy tube change is typically performed on days 5-7 post-operatively, however recent international consensus guidelines suggested that, with maturation sutures, days 3-5 is appropriate. We evaluate whether a first tube change on day 2 post-operatively is safe and effective. METHODS: We carried out a retrospective review of all patients undergoing tracheostomy between 2009 and 2018. Exclusion criteria were patients on whom the senior authors did not operate, operations done elsewhere, cases where maturation sutures were not used or a patient died prior to first tube change. We noted patient details, indication for tracheostomy, the need for long-term ventilation, timing of the first tube change, decannulation and need for surgical closure of persistent tracheocutaneous fistula. RESULTS: 93 patients were identified, of which 83 were included. The age range was 0-16 years, with the youngest day one of life and an overall mean age of 1.91 years. 59% of patients required long-term ventilation due to various co-morbidities. 26 patients (31%) underwent a first tube change on day 2 post-operatively. All these were uneventful and were irrespective of the patient's need for ventilation. Of the 42 patients who have subsequently been decannulated, 33 (79%) were noted to have a persistent tracheocutaneous fistula requiring surgical closure, four of whom needed revision closure. CONCLUSIONS: This study shows that a first tube change on day 2 post-operatively is safe, facilitating earlier discharge from intensive care, allowing shorter length of sedation, earlier start to parent/carer training and wound assessment.

Comparing two deep brain stimulation leads to one in refractory tremor.

A sizable proportion of medication refractory tremor patients may not respond satisfactorily to deep brain stimulation (DBS) to the ventralis intermedialis nucleus of the thalamus (Vim). Implanting a second DBS lead ipsilaterally to the first one is thought to be beneficial based on scarce and unblinded data. This article aims to report a double-blind assessment of five patients with a second DBS lead for refractory tremor. Tremor was assessed by two blinded movement disorder specialists using a videotaped tremor rating scale (TRS) evaluation of each patient in four conditions: both leads OFF, Vim ON/2nd lead OFF, Vim OFF/2nd lead ON, and both leads ON. Paired t-test was used to determine if double stimulation was different than stimulation of Vim alone or than stimulation of the 2nd lead alone. Each hypothesis was tested with the total TRS as well as the contralateral upper limb score and the contralateral hemibody score. Tremor was secondary to multiple sclerosis in two patients and to essential tremor in three. The second lead was in the ventralis oralis anterior nucleus of the thalamus in three patients and in the prelemniscal radiations in two patients. There was improvement with the 2nd lead or double ON in four patients compared to stimulating the Vim alone. However, when taken as a group, the results were not statistically significant. These results were constant with the three different ratings used. The lack of overall statistically significant improvement might be secondary to the small size and the heterogeneity of our sample. However, four patients had 17 to 60 % tremor improvement after the implant of the 2nd lead on double-blinded evaluation. We report objective improvement after addition of a second DBS lead in patients with tremor refractory to Vim DBS. Larger studies are needed to confirm these results.

Which approach is better: bilateral versus unilateral thalamic deep brain stimulation in patients with fragile X-associated tremor ataxia syndrome.

Fragile X-associated tremor ataxia syndrome (FXTAS) is a relatively recently described condition that is frequently misdiagnosed as essential tremor and then occasionally treated as such with deep brain stimulation (DBS) to the nucleus ventralis intermedius of the thalamus (Vim). Reports of ataxia worsening after bilateral Vim DBS in FXTAS patients are conflicting, and only five FXTAS patients treated with Vim DBS for intractable tremor have been reported in the literature, three of whom having undergone a bilateral procedure. We report a patient who underwent a staged Vim DBS procedure, with excellent contralateral hand tremor control and no worsening of ataxia after the first procedure, but immediate worsening of his ataxia after the second one, arguing in favor of a unilateral surgical approach for intractable tremor in FXTAS.

From normal gait to loss of ambulation in 6 months: a novel presentation of SCA17.

Spinocerebellar ataxias are a group of rare and heterogeneous autosomal dominant disorders characterized by progressive ataxia and other features. Spinocerebellar ataxia 17 (SCA17) is one of the 32 subtypes described to date and is secondary to CAG/CAA repeat expansion in the gene coding for the TATA-box binding protein (TBP). SCA17 is clinically heterogeneous and typically presents with slowly evolving ataxia, dysarthria, dementia, depression, and other movement disorders such as chorea. More than 41 CAG/CAA repeats are considered diagnostic of SCA17, with more than 49 being associated with full penetrance. We report one patient presenting with isolated rapidly evolving ataxia who was found to have 44 CAG/CAA repeats in the TBP gene. This suggests that, while SCA17 typically slowly progresses over years, its repertoire of presentations should be expanded to include rapidly progressive isolated ataxia resembling paraneoplastic disorders or prion disease.

Endovascular treatment of sigmoid sinus aneurysm presenting as devastating pulsatile tinnitus. A case report and review of literature.

Pulsatile tinnitus is a rare yet potentially disabling symptom that can have either vascular or nonvascular etiologies. A recently described vascular cause is an aneurysm of dural venous sinuses. To our knowledge, eight of such cases have been published, five of which were treated surgically and three by endovascular approach. We describe one additional case treated successfully by endovascular coiling and review the current data on this subject.